Harvard University Conflict Avoidance Statement

Name: [ ]

Department/Faculty: [ ]

Licensed Technology: [ ]

Licensee Company/Address: [ ]

Because of the license granted by Harvard to the above company and my Close Financial Interest in this firm, I acknowledge the potential for a possible conflict of interest between the performance of my research, teaching, administrative or other obligations at Harvard and my personal financial interests and/or contractual or other obligations to this firm. Therefore, I will not:

involve students or post-doctoral fellows at Harvard in research and development projects for the company without the prior approval of the dean or the dean’s designee;

restrict or delay general access to information from Harvard research;

alter the scope or direction of my Harvard research, if any, or the Harvard research of others; and/or

alter performance of my obligations to Harvard, whether by action or inaction, in order to materially benefit the company.

In addition, in order to avoid the appearance of a conflict, I will attempt to differentiate clearly between the intellectual directions of my Harvard research, if any, and my contributions to the company. To that end, I will report annually (i) to my department head (and/or faculty supervisor) and to the chairperson of the appropriate Faculty committee or, (ii) to the appropriate Harvard committee, office or administrator the general nature of my activities on behalf of the company and how those differ from my Harvard research or, if I am not engaged in the performance of research at Harvard, how such activities relate to the performance of my obligations to Harvard.

Finally, I understand that Faculty policy may require me to disclose that I have a financial interest in the company in any publications or public statements I make presenting research results related to this license.

Signature/Date: [ ]

Acknowledged by department head/Date: [ ]

Acknowledged by faculty supervisor(for research staff, students and post-docs)/Date: [ ]